Bill Text: NY S04929 | 2019-2020 | General Assembly | Introduced


Bill Title: Expands coverage for eating disorders; requires comparable coverage for adults and children with eating disorders; defines eating disorder.

Spectrum: Partisan Bill (Democrat 1-0)

Status: (Introduced - Dead) 2020-01-08 - REFERRED TO INSURANCE [S04929 Detail]

Download: New_York-2019-S04929-Introduced.html


                STATE OF NEW YORK
        ________________________________________________________________________
                                          4929
                               2019-2020 Regular Sessions
                    IN SENATE
                                     March 29, 2019
                                       ___________
        Introduced  by  Sen.  RIVERA -- read twice and ordered printed, and when
          printed to be committed to the Committee on Insurance
        AN ACT to amend the insurance law, in relation to  coverage  for  eating
          disorders
          The  People of the State of New York, represented in Senate and Assem-
        bly, do enact as follows:
     1    Section 1. Subsection (i) of section 3216  of  the  insurance  law  is
     2  amended by adding a new paragraph 35 to read as follows:
     3    (35)  (A)  Every  policy which provides medical coverage that includes
     4  coverage for physician services in a physician's office and every policy
     5  which provides major  medical  or  similar  comprehensive-type  coverage
     6  shall include coverage for inpatient hospitalization, partial hospitali-
     7  zation,  residential  care,  intensive  outpatient  treatment, follow up
     8  outpatient care and counseling  for  adults  and  children  with  eating
     9  disorders.  Such  coverage  shall be provided under the terms and condi-
    10  tions otherwise applicable under the policy, including  network  limita-
    11  tions  or  variations,  exclusions, co-pays, coinsurance, deductibles or
    12  other specific cost sharing mechanisms. Provided further, where a policy
    13  provides both in-network and out-of-network benefits, the out-of-network
    14  benefits may have different coinsurance, co-pays, or  deductibles,  than
    15  the  in-network  benefits,  regardless  of whether the policy is written
    16  under one license or two licenses.
    17    (B) Coverage for treatment of an eating disorder provided  under  this
    18  paragraph  is  limited to medically necessary treatment that is provided
    19  by a licensed treating  physician,  psychiatrist,  psychologist,  mental
    20  health counselor, clinical social worker, or licensed marriage and fami-
    21  ly therapist, in accordance with a treatment plan.  Such treatment plan,
    22  upon  request  by  the insurer, shall include all elements necessary for
    23  such insurer to pay claims. Such elements include, but are  not  limited
    24  to,  a  diagnosis, proposed treatment by type, frequency and duration of
    25  treatment, and goals.
         EXPLANATION--Matter in italics (underscored) is new; matter in brackets
                              [ ] is old law to be omitted.
                                                                   LBD08518-02-9

        S. 4929                             2
     1    (C) Medical necessity  determinations  and  care  management  for  the
     2  treatment  of  eating  disorders  shall consider the overall medical and
     3  mental health needs of the individual with an eating disorder, shall not
     4  be based solely on weight, and shall take into  consideration  the  most
     5  recent  Practice  Guideline  for  the  Treatment of Patients with Eating
     6  Disorders adopted by the American Psychiatric Association in addition to
     7  current standards based upon the medical literature generally recognized
     8  as authoritative in the medical community.
     9    (D) For purposes of this paragraph, the term "eating  disorder"  means
    10  pica,  rumination  disorder,  avoidant/restrictive food intake disorder,
    11  anorexia nervosa, bulimia nervosa, binge eating disorder,  other  speci-
    12  fied feeding or eating disorder, and any other eating disorder contained
    13  in  the  most recent version of the Diagnostic and Statistical Manual of
    14  Mental Disorders published by the American Psychiatric Association.
    15    § 2. Subparagraph (B) of paragraph 5 of subsection (l) of section 3221
    16  of the insurance law, as amended by chapter 502 of the laws of 2007,  is
    17  amended to read as follows:
    18    (B)  (i)  Every insurer delivering a group or school blanket policy or
    19  issuing a group or school blanket policy for delivery,  in  this  state,
    20  which  provides  coverage  for  inpatient  hospital care or coverage for
    21  physician services, shall provide comparable  coverage  for  adults  and
    22  children  with  biologically  based  mental illness. Such group policies
    23  issued or delivered in this state shall  also  provide  such  comparable
    24  coverage for children with serious emotional disturbances. Such coverage
    25  shall  be  provided  under the terms and conditions otherwise applicable
    26  under the policy, including network limitations  or  variations,  exclu-
    27  sions,  co-pays, coinsurance, deductibles or other specific cost sharing
    28  mechanisms. Provided further, where a policy  provides  both  in-network
    29  and  out-of-network  benefits,  the  out-of-network  benefits  may  have
    30  different coinsurance, co-pays,  or  deductibles,  than  the  in-network
    31  benefits,  regardless of whether the policy is written under one license
    32  or two licenses.
    33    (ii) For purposes of this  paragraph,  the  term  "biologically  based
    34  mental  illness" means a mental, nervous, or emotional condition that is
    35  caused by a biological disorder of the brain and results in a clinically
    36  significant, psychological syndrome or pattern that substantially limits
    37  the functioning of the person with the illness. Such biologically  based
    38  mental illnesses are defined as schizophrenia/psychotic disorders, major
    39  depression,  bipolar  disorder,  delusional  disorders,  panic disorder,
    40  obsessive compulsive disorders[, bulimia, and  anorexia]  or  an  eating
    41  disorder.
    42    (iii)  (I) For purposes of this subsection, the term "eating disorder"
    43  means pica, rumination disorder, avoidant/restrictive food intake disor-
    44  der, anorexia nervosa, bulimia nervosa,  binge  eating  disorder,  other
    45  specified  feeding  or  eating  disorder,  and any other eating disorder
    46  contained in the most recent version of the Diagnostic  and  Statistical
    47  Manual of Mental Disorders published by the American Psychiatric Associ-
    48  ation.
    49    (II)  Notwithstanding  any  provision of this section to the contrary,
    50  coverage for  treatment  of  an  eating  disorder  provided  under  this
    51  subsection shall include inpatient hospitalization, partial hospitaliza-
    52  tion, residential care, intensive outpatient treatment, follow up outpa-
    53  tient  care and counseling, provided, however, such treatment is limited
    54  to medically necessary treatment that is provided by a licensed treating
    55  physician, psychiatrist, psychologist, mental health counselor, clinical
    56  social worker, or licensed marriage and family therapist, in  accordance

        S. 4929                             3
     1  with  a treatment plan. Such treatment plan, upon request by the medical
     2  expense indemnity  corporation  or  health  service  corporation,  shall
     3  include  all elements necessary for such corporation to pay claims. Such
     4  elements  include,  but are not limited to, a diagnosis, proposed treat-
     5  ment by type, frequency and duration of treatment, and goals.
     6    (III) Medical necessity determinations and  care  management  for  the
     7  treatment  of  eating  disorders  shall consider the overall medical and
     8  mental health needs of the individual with an eating disorder, shall not
     9  be based solely on weight, and shall take into  consideration  the  most
    10  recent  Practice  Guideline  for  the  Treatment of Patients with Eating
    11  Disorders adopted by the American Psychiatric Association in addition to
    12  current standards based upon the medical literature generally recognized
    13  as authoritative in the medical community.
    14    § 3. Paragraph 2 of subsection (g) of section 4303  of  the  insurance
    15  law,  as  amended by chapter 502 of the laws of 2007, is amended to read
    16  as follows:
    17    (2) (A) A hospital service corporation  or  a  health  service  corpo-
    18  ration,  which provides group, group remittance or school blanket cover-
    19  age for inpatient hospital care, shall provide comparable  coverage  for
    20  adults  and children with biologically based mental illness. Such hospi-
    21  tal service corporation or health service corporation shall also provide
    22  such comparable coverage for children with  serious  emotional  disturb-
    23  ances.  Such  coverage  shall be provided under the terms and conditions
    24  otherwise applicable under the contract, including  network  limitations
    25  or  variations,  exclusions,  co-pays, coinsurance, deductibles or other
    26  specific cost sharing mechanisms. Provided  further,  where  a  contract
    27  provides both in-network and out-of-network benefits, the out-of-network
    28  benefits  may  have different coinsurance, co-pays, or deductibles, than
    29  the in-network benefits, regardless of whether the contract  is  written
    30  under one license or two licenses.
    31    (B)  For  purposes  of  this  subsection, the term "biologically based
    32  mental illness" means a mental, nervous, or emotional condition that  is
    33  caused by a biological disorder of the brain and results in a clinically
    34  significant, psychological syndrome or pattern that substantially limits
    35  the  functioning of the person with the illness. Such biologically based
    36  mental illnesses are defined as schizophrenia/psychotic disorders, major
    37  depression, bipolar  disorder,  delusional  disorders,  panic  disorder,
    38  obsessive  compulsive  disorders[,  anorexia,  and bulimia] or an eating
    39  disorder.
    40    (C) (i) For purposes of this subsection, the  term  "eating  disorder"
    41  means pica, rumination disorder, avoidant/restrictive food intake disor-
    42  der,  anorexia  nervosa,  bulimia  nervosa, binge eating disorder, other
    43  specified feeding or eating disorder,  and  any  other  eating  disorder
    44  contained  in  the most recent version of the Diagnostic and Statistical
    45  Manual of Mental Disorders published by the American Psychiatric Associ-
    46  ation.
    47    (ii) Notwithstanding any provision of this section  to  the  contrary,
    48  coverage  for  treatment  of  an  eating  disorder  provided  under this
    49  subsection shall include inpatient hospitalization, partial hospitaliza-
    50  tion, residential care, intensive outpatient treatment, follow up outpa-
    51  tient care and counseling, provided, however, such treatment is  limited
    52  to medically necessary treatment that is provided by a licensed treating
    53  physician, psychiatrist, psychologist, mental health counselor, clinical
    54  social  worker, or licensed marriage and family therapist, in accordance
    55  with a treatment plan. Such treatment plan, upon request by the  medical
    56  expense  indemnity  corporation  or  health  service  corporation, shall

        S. 4929                             4
     1  include all elements necessary for such corporation to pay claims.  Such
     2  elements  include,  but are not limited to, a diagnosis, proposed treat-
     3  ment by type, frequency and duration of treatment, and goals.
     4    (iii)  Medical  necessity  determinations  and care management for the
     5  treatment of eating disorders shall consider  the  overall  medical  and
     6  mental health needs of the individual with an eating disorder, shall not
     7  be  based  solely  on weight, and shall take into consideration the most
     8  recent Practice Guideline for the  Treatment  of  Patients  with  Eating
     9  Disorders adopted by the American Psychiatric Association in addition to
    10  current standards based upon the medical literature generally recognized
    11  as authoritative in the medical community.
    12    §  4.  Paragraph  2 of subsection (h) of section 4303 of the insurance
    13  law, as amended by chapter 502 of the laws of 2007, is amended  to  read
    14  as follows:
    15    (2)  (A)  A  medical expense indemnity corporation or a health service
    16  corporation, which provides group, group remittance  or  school  blanket
    17  coverage  for  physician services, shall provide comparable coverage for
    18  adults and children with biologically based mental illness. Such medical
    19  expense indemnity corporation or health service corporation  shall  also
    20  provide  such  comparable  coverage  for children with serious emotional
    21  disturbances. Such coverage shall be provided under the terms and condi-
    22  tions otherwise applicable under the contract, including network limita-
    23  tions or variations, exclusions, co-pays,  coinsurance,  deductibles  or
    24  other  specific  cost  sharing  mechanisms.  Provided  further,  where a
    25  contract provides both in-network and out-of-network benefits, the  out-
    26  of-network  benefits may have different coinsurance, co-pays, or deduct-
    27  ibles, than the in-network benefits, regardless of whether the  contract
    28  is written under one license or two licenses.
    29    (B)  For  purposes  of  this  subsection, the term "biologically based
    30  mental illness" means a mental, nervous, or emotional condition that  is
    31  caused by a biological disorder of the brain and results in a clinically
    32  significant, psychological syndrome or pattern that substantially limits
    33  the  functioning of the person with the illness. Such biologically based
    34  mental illnesses are defined as schizophrenia/psychotic disorders, major
    35  depression, bipolar  disorder,  delusional  disorders,  panic  disorder,
    36  obsessive  compulsive  disorder[,  anorexia,  and  bulimia] or an eating
    37  disorder.
    38    (C) (i) For purposes of this subsection, the  term  "eating  disorder"
    39  means pica, rumination disorder, avoidant/restrictive food intake disor-
    40  der,  anorexia  nervosa,  bulimia  nervosa, binge eating disorder, other
    41  specified feeding or eating disorder,  and  any  other  eating  disorder
    42  contained  in  the most recent version of the Diagnostic and Statistical
    43  Manual of Mental Disorders published by the American Psychiatric Associ-
    44  ation.
    45    (ii) Notwithstanding any provision of this section  to  the  contrary,
    46  coverage  for  treatment  of  an  eating  disorder  provided  under this
    47  subsection shall include inpatient hospitalization, partial hospitaliza-
    48  tion, residential care, intensive outpatient treatment, follow up outpa-
    49  tient care and counseling, provided, however, such treatment is  limited
    50  to medically necessary treatment that is provided by a licensed treating
    51  physician, psychiatrist, psychologist, mental health counselor, clinical
    52  social  worker, or licensed marriage and family therapist, in accordance
    53  with a treatment plan. Such treatment plan, upon request by the  medical
    54  expense  indemnity  corporation  or  health  service  corporation, shall
    55  include all elements necessary for such corporation to pay claims.  Such

        S. 4929                             5
     1  elements  include,  but are not limited to, a diagnosis, proposed treat-
     2  ment by type, frequency and duration of treatment, and goals.
     3    (iii)  Medical  necessity  determinations  and care management for the
     4  treatment of eating disorders shall consider  the  overall  medical  and
     5  mental health needs of the individual with an eating disorder, shall not
     6  be  based  solely  on weight, and shall take into consideration the most
     7  recent Practice Guideline for the  Treatment  of  Patients  with  Eating
     8  Disorders adopted by the American Psychiatric Association in addition to
     9  current standards based upon the medical literature generally recognized
    10  as authoritative in the medical community.
    11    §  5.  This  act shall take effect on the ninetieth day after it shall
    12  have become a law; provided, however, that the provisions  of  this  act
    13  shall apply to policies and contracts issued, renewed, modified, altered
    14  or amended on or after such effective date.
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